Provider Demographics
NPI:1376220384
Name:JUSTICE, NATHAN BRENT
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:BRENT
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 GRACE STREET
Mailing Address - Street 2:
Mailing Address - City:JUSTICE
Mailing Address - State:WV
Mailing Address - Zip Code:24851
Mailing Address - Country:US
Mailing Address - Phone:304-928-3113
Mailing Address - Fax:
Practice Address - Street 1:67 GRACE STREET
Practice Address - Street 2:
Practice Address - City:JUSTICE
Practice Address - State:WV
Practice Address - Zip Code:24851
Practice Address - Country:US
Practice Address - Phone:304-928-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000982225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant